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Full text of "Navy Department BUMED News Letter Vol. 5, No. 1, January 5, 1945"

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Resrricred 



NAVY DBPASLTMBNT 




a dicjest of timelij information. 



Editor - Comdr. F. R. Bailey, (mc) u. s. n. r. 



Vol. 5 



Friday, January 5, 1945 



No. 1 



XABLE OF C ONTENTS 



Cholera • 1 

Alkaline Electrolyte Solutions 6 

Penicillin in Lung Surgery 7 

Penicillin in Compound Fractures 7 

Penicillin in Osteomyelitis 7 

Penicillin in Congenital Syphilis 9 

Effects of Drinking Sea Water 10 

Plastics in Bone Surgery 12 



Resuscitation of Severely Wounded. . 1 3 

Glomerulosclerosis in Diabetes 19 

Condylomata Acuminata 20 

Salt Water for Ships' Laundries 21 

Tuberculosis Control in Navy 21 

.Enteric- Coated Salt Tablets .23 

Dermatosis of Unknown Etiology 24 

Public Health Foreign Reports 25 



Form Letters: 



Quarterly Sanitary Report, Changes In.... 
Use of Service or Officer's File Number. 



.BuMed 26 

.BuMed 31 



****** 



CHOLERA 



nongraphic Distribution : For centuries cholera has been endemic m 
Asia (see Map) spreading from there to both tropical and temperate regions 
of the globe. Numerous pandemics have originated in endemic centers in 
India. Outbreaks have occurred also for many years along the coastal areas 
of China and have tended to follow the main waterways inward. Since the be- 
ginning of the war in 1937 cholera has spread inland and large numbers of 
cases were reported in 1940 in Fukien, Chekiang and Kwangtung Provinces. 
During the summer of 1944 outbreaks were reported in India and in southern 
provinces of China. 

Season : Although the disease occurs during, all months of the year, by 
far the greatest number of cases develops in the spring and summer. 

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Transmission: The cholera vibrio gains entrance into the intestinal tract 
when one ingests contaminated food or drink. Infected water supplies have 
been responsible for many epidemics. Human carriers are a source of in- 
fection, and flies are known to transport the organisms. 

Clinical Picture: The incubation period of cholera is short, ranging 
from a few hours to five or six days. The onset is characterized by profuse 
diarrhea which is usually associated with persistent vomiting. As the bowel 
is rapidly cleared of fecal matter, the stool soon consists of almost clear 
water, shreds of mucus and cellular debris (rice-water stool). With the ex- 
tremely rapid and continued loss of fluid from the tissues and blood into the 
bowel a characteristic and expected train of symptoms and signs ensues. 
The body tissues shrink, thirst becomes intense, the pulse becomes rapid 
and weak, the blood pressure falls markedly, secretion of urine diminishes 
or stops^and the body temperature may become subnormal. Acidosis de- 
velops owing to loss of base into the bowel, and uremia as a result of oli- 
guria or anuria. The severity of cholera may vary greatly, certain pa- 
tients remaining ambulatory while others die within the space of a few hours 
following dramatic and profound collapse. When recovery takes place, al- 
though convalescence is usually protracted, serious after-effects are rarely 
noted. The case fatality rate is approximately 50 per cent. 



Diagnosis: In the vicinity of known cases of cholera any patient de- 
veloping a severe diarrhea should be suspected of having cholera and should 
be hospitalized immediately. Acute diarrheas from other causes must be 
differentiated. Severe cases of bacillary dysentery caused by the Shigella 
dysenteriae (Shiga) often present a similar clinical picture. In the case of 
diarrheas due to the salmonellae or to staphylococcal toxin, vomiting usu- 
ally precedes diarrhea. An accurate diagnosis can be made only by bacterio- 
logical methods. The Vibrio cholerae maybe grown from stool inocula in 
alkaline peptone broth. It is agglutinated by specific diagnostic sera. 

Rough technics, the successful use of which requires considerable ex- 
perience, include hanging-drop preparations of the feces in which the rapid 
rotary movement of the vibrio may be observed, and direct fecal smears 
stained with carbol fuchsin in which the organisms tend toward a "fish in 
stream" arrangement. 

Treatment : While it is apparent that many of the clinical manifestations 
of cholera suggest the action of a potent bacterial toxin and, in fact, an endo- 
toxin has been demonstrated, as yet no effective antitoxic sera are available. 
Primary treatment, therefore, is supportive and is directed in the main to- 
ward combatting dehydration and preventing acidosis and uremia. 

It may be difficult to give fluids by mouth because of nausea and vomit- 
ing. Furthermore, orally-taken fluid may act to stimulate peristalsis and 
excretion into the bowel. However, as much fluid as can be tolerated should 
be administered by mouth. The presence of circulatory collapse will re- 
sult in poor absorption of subcutaneously-injected fluid. Consequently, i n 
practically all cases fluids must be given intravenously. In severe cases enor- 
mous amounts of fluid will be required for replacment, and it is important 
that intravenous administration be continuous throughout the day and night. 

Two factors predispose to acidosis in diarrhea. First, there is a greater 
loss in diarrheal stools of sodium and other cations (bases) than of chloride 
and other anions (acids) . Second, the impaired renal function incident to the 
dehydration results in the retention of acid catabolites. 

There results, therefore, a metabolic acidosis with a decrease in serum 
HCO3 and increase in the other anions (HPO4, SO 4 and Prot. ~). The star- 
vation also leads to ketosis. When diarrhea is complicated by vomiting, the 
loss of chloride in the gastric juice may limit somewhat the degree of aci- 
dosis. In any instance, however, the loss of sodium and chloride will be ex- 
cessive. The presence of hyperpnea may help to indicate the existence and 
degree of acidosis.- 




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Because of the loss of both sodium and chloride, physiologic saline (0.85 
Gm. NaCl per 100 c.c.) should be administered intravenously in large amounts. 
In the presence of acidosis supplementary sodium bicarbonate or sodium lac- 
tate should be added. A suitable solution of saline and supplementary sodium 
results from the addition of one part of M/6 sodium lactate solution or M/6 
sodium bicarbonate solution to two parts of physiologic (0.85 per cent) sodi- 
um chloride solution. This provides a solution for water and electrolyte re- 
placement with sodium and chloride concentrations approximately equal to 
normal serum sodium and chloride concentrations and a bicarbonate concen- 
tration great enough to correct acidosis but not excessive enough to produce 
alkalosis. This solution should contain also glucose in a concentration of ap- 
proximately 5 per cent to provide calories and to combat ketosis. 

The fever, toxemia, starvation and loss of body substance will result in 
a markedly negative nitrogen balance. After rehydration and electrolyte 
replacement, transfusions of isotonic plasma or albumin may be desirable 
in order to maintain an adequate plasma protein concentration. Whole blood 
transfusions may be beneficial in order to sustain both plasma protein and 
hemoglobin concentrations. Because the diarrhea and vomiting may be ag- 
gravated by the oral ingestion of food, amino acids (Amigen) may be added 
to the intravenous infusion up to 3 per cent concentration. If Amigen i s 
given too fast by infusion, nausea, vomiting and hyperthermia may result. 

If the serum Na and CI remain considerably below their respective 
normal concentrations in spite of the infusion of physiologic saline, 1.2 Gm. 
NaCl per 100 c.c. may be infused for a short time. Saline solutions more 
concentrated than this appear undesirable. 

Where laboratory facilities are available, much information as to the 
effectiveness of early supportive therapy may be obtained from some of the 
following determinations: hemoglobin, hematocrit, plasma specific gravity ( 
or plasma protein concentration (copper sulphate method) , blood or serum 
NPN, and serum COg content and chloride concentration. 

Opinions differ as to the efficacy of the sulfonamides. In a study con- 
ducted in Madras under the auspices of the International Health Division of 
the Rockefeller Foundation (Burned News Letter, Nov. 26, '43) sulfaguani- 
dine was administered to alternate cases. While beneficial results with 
sulfaguanidine were not striking, clinical trial of sulfadiazine may be justi- 
fied. However, the use of this drug carries with it great hazard of urinary 
complications if it is administered prior to the resumption and maintenance 
of an adequate flow of urine. 

Good nursing care is essential. The patient should be kept comfortably 
warm during the period of collapse. Patients with cholera are subject to 



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sudden relapses, and immediate resumption of intravenous treatment may be 
required. 

prevention: 

1. General measures in areas where cholera is endemic include: (a) main- 
taining a satisfactory water supply by chlorination or boiling; Cb) avoidance of 
uncooked foods; (c) meticulous control of milk supply; (d) adequate fly control 
measures and (e) detection and isolation of carriers. 

2. Isolation of patients and carriers should conform to rigid enteric- 
disease isolation standards. 

3. Immunization : An immunity of short duration, probably six to twelve 
months, may be produced by vaccination as recommended in the Navy. The 
vaccine is given in two subcutaneous injections, of 0.5 c.c. and 1.0 c.c. of vac- 
cine from seven to ten days apart. A booster of 1.0 c.c. is given every six 
months while in an endemic area. The vaccine is composed of a suspension 
of killed cholera organisms, 8,000 million per c.c. Equal numbers of organ- 
isms of the Inaba and Ogawa strains are used in the preparation of this vaccine. 

Some of the vaccines used locally in China and mdia are made from freshly 
isolated organisms secured from patients during the early stage of an epidemic. 
Anticholera vaccines used in India are prepared from a mixture of three to six 
or more strains. Such vaccines in the presence of epidemics have proved bene- 
ficial in the prevention and control of cholera. 

Trends of current research in the immunology of cholera are illustrated 
by the following: 

A new type of cholera vaccine has been described by Jenning. This con- 
sists of an entire liquid culture of the vibrio, killed with phenyl mercuric ni- 
trate and used directly in the original medium - a medium developed to support 
a very heavy growth. The preliminary report of the degree of immunity con- 
ferred by this vaccine is encouraging. It has the great advantage of simplicity 
in quantity production. 

The cholera vaccines in present use are antibacterial but apparently 
stimulate no resistance to endotoxic substances. Burrows has purified an 
endotoxin in the form of a toxic phospholipid which has a molecular size 
small enough to permit dialysis. In a saline suspension this lipid is a non- 
toxic complete antigen which appears to be a considerably more efficient im- 
munizing agent than vibrio suspensions. Further studies on the characteristics 
of the toxin are in progress. This work on new types of vaccine is still in the 
experimental stage. 



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Current investigations have attempted to analyze the complex antigenic 
structure of Y_. cholerae. Burrows reports that antigen "A" is found in the 
cholera vibrios of Group I, and recommends immunologic types designated 
"A", "AB", "AC^ and "ABC". In such a system Ogawa strains roughly 
approximate type "AB" and Inaba strains correspond closely to type "AG". 
The application of vibrio typing to epidemiologic problems in the field should 
prove valuable. 

4 - Chemoprophvlaxis: At present there is no evidence available that 
the sulfonamides or other chemotherapeutic agents used prophylactically are 
effective in the prevention of cholera. (Prev. Med. Div., BuMed - J. K. Curtis- 
Prof. Div., BuMed - F. A. Butler. Dr. Henry Meleney and Dr. Allan Butler ' 
kindly reviewed the manuscript and made helpful suggestions.) 

* * 

Formulae of Lac tate and Bicarbonate RnlTitTnns- 

Sodium Lactate M/6* Sodium-r-lactate 18.7 Gm. 

Distilled water 1,000.0 c.c. 

Sodium Bicarbonate M/6** Sodium bicarbonate 14.0 Gm. 

Distilled water 1,000.0 c.c' 

*Can be purchased in ampoules in concentrated (molar) sterile solution 
(which must be diluted six times) or in M/6 sterile solution from various 
drug manufacturers (Abbott, Baxter, Lilly, Upjohn, etc.). 

**Can be obtained commercially in concentrated sterile solution (Abbott). 

Also can be prepared as follows: Boil 1,000 c.c. distilled water. Remove 
from heater and at once add sodium bicarbonate (14 Gm.) which has been taken 
directly from the original container and weighed in a sterile vessel. Cover and 
allow to stand for 20 minutes; then cool to body temperature and use at once. 

Caution: This solution should not be sterilized by boiling or autoclaving 
as the temperatures reached during these procedures will change the bicar- 
bonate to the caustic carbonate. 

The Medical Materiel Board has under consideration the addition of 
sodium lactate soldtion to the Supply Table. 



****** 



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Penicillin in Prevention of Postoperative Empyema Following Lung Re- 
section: A study has recently been made of the effectiveness of penicillin in 
the prevention of postoperative empyema following lung resection. Patients to 
whom penicillin was administered were paired as closely as possible with 
comparable controls. The treated patients received 150,000 units daily 
divided into equal doses injected intramuscularly at two-hour intervals for 
one week pre-operatively and two weeks postoperatively. No penicillin was 
injected locally into the pleural space before, during, or after operation un- 
less an obvious empyema had developed, in which case the experimental re- 
sult had already been determined. In the event that empyema developed in 
the control cases, they received penicillin therapy by various routes in an 
effort to control the infection. No other specific therapy was used either 
systemically or locally in the treated or control cases. As far as possible 
the operative technic was made uniform. 

It was found that the patients with bronchiectasis or multiple lung ab- 
scesses who received penicillin showed no evidence of postoperative intra- 
pleural infection, had less fever and fewer days of tube drainage, were allowed 
out of bed earlier and were discharged sooner than the control cases. All of 
the control cases developed empyema. 

Penicillin was found not to be effective in preventing tuberculous empye- 
ma in patients with tuberculosis who were subjected to partial or total lung 
resection. 

It was concluded that penicillin administered in the manner described was 
useful in preventing pyogenic infections following lobectomy or pneumonectomy. 
(White, Univ. of Pa., OEMcmr-56.) 

****** 

Penicillin in Patients with Compound Fractures : Results obtained in 28 pa- 
tients with compound fractures who were given penicillin pr ophylactically have 
been compared with results in 32 similar cases which were given sulfadiazine. 
The penicillin appears to have been more effective , particularly in reducing the 
number of soft-tissue infections. In two cases the use of penicillin pre- and 
postoperatively permitted a successful surgical attack on a frankly infected field. 

Proper debridement appears to be the most important factor in preventing 
infection in compound fractures, whether or not penicillin is used. (Reynolds, 
Univ. of 111., OEMcmr-426; Progress Report #4, CMR Bulletin #17.) 

^ *^ *^ ^ 

The Use of Penicillin in Chronic Osteomyelitis: A questionnaire was sent 
to nine investigators actively engaged in studying the use of penicillin in the 



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treatment of patients with chronic osteomyelitis of hematogenous. origin. The 
questions asked and a summary of the replies received are presented here: 

1. Do you believe that patients with recurrence or persistence of active 
infection can be successfully treated with penicillin alone, without surgical 
intervention? If so, under what circumstances? 

None of the investigators thinks that penicillin alone will clear up an 
infection associated with formation of a sequestrum, and the great majority 
thinks that penicillin treatment is most effective in these cases when combined 
with surgery. It is believed that penicillin given preoperatively is of great 
value and that emphasis should be on preoperative rather than postoperative 
chemotherapy. An acute flare-up without sequestrum formation may sub- 
side with penicillin treatment alone, but there is no assurance that the drug 
will have a curative effect, and it is probably wiser to carry out surgery in 
all such cases. Chronic infections of the pelvis and other flat bones and of 
vertebral bodies may become quiescent for long periods after penicillin 
therapy; this is helpful in the management of cases in which the lesions can- 
not readily be approached for radical surgical treatment. 

2. What dosage do you recommend, and how do you determine the dura- 
tion of preoperative therapy? 

Most investigators use 160,000 to 200,000 units per day for 3 to 5 days 
preoperatively and continue treatment at this level for about a week after 
operation. A typical course of treatment would involve 20,000 to 25,000 units 
every 3 hours intramuscularly for 3 days before operation and a week after 
operation. 

3. When surgery is performed, what findings do you use as a guide in 
determining the scope of the surgical procedure ? 

All investigators recommend removal of sequestra, and seven specifically 
recommend excision of all obviously infected scar tissue and bone. Only one 
recommends complete saucerization. 

4. How early do you permit the operative wound to close? 

Four of the reporters practice primary closure of the operative wound 
following preoperative preparation with penicillin. One recommends pro- 
longed Orr treatment with changing of plaster casts every 1 to 3 weeks. The 
others leave the wounds open but permit them to close spontaneously and find 
most wounds healed within 14 days. 

5. Do you use penicillin locally in the wound? Why? How? 



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Eight investigators use penicillin locally in some form. Three use small 
catheters to introduce drug solution into the wounds for a few days after opera- 
tion, and three use daily reapplications in conjunction with change of dressings. 
The justification for local penicillin is to hold down bacterial growth to a mini- 
mal level during formation of the primary wound barrier. 

6. Have you encountered secondary recurrences of infection in lesions 
treated with combined surgery and penicillin? 

Six of the ten reporters have seen secondary recurrences of local infec- 
tion. One attributes these late recurrences to the presence of resistant o r 
Gram-negative or ganisms and two attribute them to inadequate 
surgery. 

7. Do you distinguish between infections of cortical bone and cancellous 
bone in respect to the probable results of penicillin therapy? 

There was no consistent tendency to differentiate between infections of corti- 
cal and those of cancellous bone in respect to end results of penicillin treatment. 

8. To what extent does the presence of Gram-negative bacilli or other 
penicillin-resistant organisms interfere with the results of combined peni- 
cillin and surgical treatment ? 

Two individuals believe that the presence of Gram-negative organisms 
interferes with the successful use of penicillin in chronic cases. However, 
three state that the presence of Gram-negative organisms is of little im- 
portance provided surgical treatment is adequate. A large majority of those 
reporting seems to believe that the presence of Gram-negative organisms 
does not require any difference in the type of management from that used in 
cases with pure cultures of Staphylococcus aureus. (CMR Bulletin #19). 

* * 

This questionnaire was prepared by J. S. Lockwood. Investigators con- 
sulted were: W. A. Altemeier, D. G. Anderson, J. Buchman, O. J. Hermann, 
J. W. Hirshfeld, R. D. McClure, F. L. Meleney, A Ochsner, and J. E. Rhoads. 

****** 

penicillin in Treatment of Congenital Syphilis -. Satisfactory follow-up 
observations for 4 months or more are available for 25 of a group of 33 cases 
of congenital syphilis treated with 20,000 units of penicillin per kg. "Of these 
25, all except one are apparently cured of all manifestations. This one infant 
had clinical relapse on roentgenographic evidence only - recurrence of osseous 



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lesions 6 months after completing therapy and 2 months after a sharp rise 
in serolpgic titer." 

An additional 50 cases have been treated on the same schedule. None 
has been followed as long as 4 months but clinical improvement occurred in 
all except one infant, moribund at the initiation of therapy. 

"Reactions during treatment have been noted in about 1/3 of all cases. 
These consisted of transient urticaria (in only 2 infants) and fever, usually 
not exceeding 102°, and occurring within the first 3 days of administering 
penicillin." (Platou, Tulane Univ., OEMcmr-461; Progress Report #2, 
CMR Bulletin #17) 

****** 

Physiologic Effects of Drinking Undiluted Sea Water: Men cast adrift 
on the open sea without fresh water often succumb to the temptation to drink 
sea water. It has been stated that the drinking of sea water is probably, next 
to exposure to cold, the most common cause of death under such conditions. 
Although the existence of an unfavorable response to such ingestion has been 
widely recognized, there has been no agreement concerning the exact nature 
of the disturbance or its physiological basis. In a recent paper Elkington and 
Winkler review certain recent clinical and experimental observations which ■ 
indicate the cause of these deleterious physiological effects. 

Although there are many differences among the symptoms exhibited by 
men who have ingested large amounts of sea water, disturbances of the nerv- 
ous system generally predominate. The mind is usually affected, and suicidal 
attempts are common. 

Modern views seek to relate the ill effects of the drinking of sea water 
in some way to its hypertonicity, since large amounts can apparently be in- 
gested if sufficiently diluted with fresh water. Sea water is a salt solution 
with an average concentration of 3.5 per cent. The principal cation is sodi- 
um and the principal anion chloride. Magnesium and sulphate are also present 
in smaller amounts, but these ions are not in themselves toxic when ingested 
orally. They may cause diarrhea. In composition, therefore, sea water 
closely resembles vertebrate extracellular fluid, except that its total ionic 
concentration is about four times as great. Since the highest recorded con- 
centration of sodium as sodium chloride in human urine is 1.9 per cent, the 
ingestion of undiluted sea water presents a dilemma to the organism. Either 
some of the ingested sodium chloride must fail of excretion, or body water 
must be sacrificed in order that the salt may be excreted in its entirety in 
the' urine. The physiologic dilemma is only aggravated by the fact that part 



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of the salt in sea water Is magnesium sulphate, because ingested magnesium 
and sulphate are largely excreted by the intestine in isotonic solution. They 
require, therefore, even more water per mol for their excretion than do sodi- 
um and chloride, which are excreted in hypertonic solution in the urine. The 
actual response of the organism will inevitably depend on many factors, in- 
cluding the state of hydration of the body and the- rate of ingestion of sea water. 
In any case hypertonicity of the body fluids must result. The character of 
this hypertonicity depends, however, on whether or not salt is retained. With 
no retention of sodium chloride, loss of fluid is distributed over both 'extra- 
cellular and intracellular compartments in proportion to their initial magni- 
tudes. With retention of this salt, however, a new situation develops, since 
sodium and chloride are largely excluded from the cellular phase of tissues. : 
Any sodium or chloride retained from sea water must be confined mainly to ' 
the extracellular phase, with a resultant osmotic shift of water from cells to 
extracellular fluid. Contraction of the extracellular phase is therefore mini- 
mized at the expense of an exaggerated depletion of the intracellular fluid. 

The authors administered sodium chloride to dogs, while the total water 
intake was unchanged or slightly decreased. The tonicity of the body fluids 
rose sharply. There was a large retention of sodium and chloride and, a s a 
result of osmosis, a large shift of water from the intracellular to the extra- 
cellular phase. 

In other experiments, small amounts of a 5 per cent solution of sodium 
chloride were given repeatedly for 4 to 6 days to animals previously deprived 
of food and water for some time. In spite of this prior dehydration, the body 
sacrificed still more of its water and eliminated some but not all of the i n - 
gested salt in the urine. Because of this retention of salt and loss of water, 
hypertonicity of the body fluids rapidly developed. Water without base was 
withdrawn from the intracellular compartment in response to the retention 
of sodium chloride in the latter. Some potassium salts also were lost from 
the cells during this process. As a result, extracellular volume was fairly 
well maintained in spite of progressive total dehydration, while the intra- 
cellular fluid bore the brunt of the loss. The intracellular dehydration pro- 
gressed steadily until the end. Concentration of salt in the urine gradually 
rose. At no time, however, did the concentrations of these ions in the urine 
equal those in the solution injected. 

Shortly before death the animals exhibited various disturbances of the 
nervous system, including tremors, hyperactive reflexes, motor incoordina- 
tion and finally irregular and failing respiration. The circulation in the mean 
time continued to function well. There was no decrease in the plasma volume 
such as is commonly seen in peripheral vascular collapse; renal excretion re 
mained active; the pulse was vigorous, and electrocardiograms were normal. 
The picture was clearly not one of circulatory failure, either of the car diac 



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muscle or of the peripheral circulation. The terminal event was failure of 
the respiration. 

These experiments indicate that following the continued ingestion o f 
hypertonic sodium -chloride solution, owing to the retention of some of the 
salt, the extracellular fluid tends to be maintained at the expense of exces- 
sive depletion of intracellular fluid. 

No direct experiments involving the later stages of ingestion of hyper- 
tonic saline solution by human beings are available, and one can only reason 
by analogy with these experiments on dogs. The clinical behavior of those 
survivors of shipwreck who persistently .drink sea water lends support, how- 
ever, to the validity of this analogy. The status of these subjects is compa- 
rable to that of the dogs which, following deprivation of water and food, had 
received hypertonic saline over a considerable period of time. Functional 
disturbances of the central nervous system predominate over any signs of 
cardiovascular collapse. This is precisely the result which might be ex- 
pected if the extracellular fluid volume were maintained at the cost of 
severe intracellular dehydration. Both from the experiments on dogs cited 
here and from many other sources it is clear that the plasma volume and 
the integrity of the peripheral circulation depend primarily on the state of 
the extracellular rather than the intracellular fluid. Both volume and salt 
concentration are important; but with only moderate reduction in the former 
and with hypertonicity of the latter there is no physiologic reason why the 
circulation should be inadequate. Disturbances of the central nervous sys- 
tem, on the other hand, were present in the authors' experiments on dogs 
and were there associated with extreme intracellular dehydration. Under 
some conditions cells apparently can function until they lose 40 to 50 per 
cent of their water, but there must be a limit to the degree of desiccation 
in which the complex metabolism of the cell can continue. Participation of 
the cells of the central nervous system in the general cellular dehydration 
would explain the clinical manifestations both in these dogs and in the survi- 
vors of shipwreck drinking sea water. Such intracellular dehydration would 
necessarily result if the renal reactions of human beings in the later stages 
parallel those of dogs. (War Med., Oct. '44.) 

****** 

Plastics f or Bone Grafts. Bone Support and Fracture Pinning: Captain 
G. Blum, RAMC, has continued his studies on improved plastics for bone 
grafts, bone support and fracture pinning. The non- absorbable transparent 
plastic, methyl methacrylate, may be applied and molded into the desired 
shape as a soft "dough". Then by the application of ordinary ultraviolet 
light full hardening can be accomplished in 15 minutes. Captain Blum has 
also studied absorbable protein plastics extensively. These are prepared 



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by treating casein, fibrin, whole blood or red blood cells with formalin. De- 
pending on the treatment almost any hardness can be obtained. Screws, pins, 
plates, etc., can be made of sufficient strength to bear the required weight 
and to withstand operative manipulation. Admittedly these absorbable plas- 
tics are not as strong or as non-frangible as steel. Casein and fibrin plastics 
placed in animals' bones disappear, i.e., are absorbed, in six months. Blum 
has estimated that plastics of the size ordinarily used in human patients would 
be absorbed in about a year. Microscopically, in contrast to the methyl 
methacrylate plastics, there is very little foreign body reaction about the 
absorbable grafts, pins or screws. Recently two patients have had major 
fractures pinned by casein screws. No difficulties were encountered in the 
applications; it is too early to report results. There is one minor disad- 
vantage to the use of these protein plastics. They are not radio-opaque. 
(G. Blum, from report to meeting of Middlesex Physiological Society. CMR, 
London News Letter #113, Southworth.) 

****** 

Resuscitation of the Severely Wounded : Recently a report was made to 
the Associate Committee on Army Medical Research of the National Research 
Council of Canada by Lt. Col. A. L. Chute, O.B.E., Commanding Officer, No. 1 
Research Laboratory, 'RCAMC. This report represents observations made 
and opinions formed by the members of the Research-Laboratory Unit and 
other surgeons in the Italian Theater of Operations as a result of a careful 
clinical and laboratory study of casualties. 

Signs of Shock: Clinical signs are sufficiently definite to make assess- 
ment of the severity of wound shock practical. Since early and adequate treat- 
ment is the keystone of success, it is imperative to recognize and weigh the 
relative importance of each sign. There are no readily available laboratory 
tests which will supply this information. 

The extent and nature of the injury are of prime importance in evaluating 
the condition of the casualty. It is essential to emphasize that wounds should b e 
carefully examined in an endeavor to determine their seriousness. This informa- 
tion must be correlated with the signs discussed below if adequate treatment 
is to be given. 

Paleness usually indicates a moderate degree of shock. Those who have 
suffered excessive blood loss are chalky white. Cyanosis of lips, lobes of 
ears and finger tips may be present in the severely wounded. In very severe 
collapse the skin of hands, feet and other parts of the body may be a blotchy 
purple. The color of the skin, blanched by pressure, returns slowly on re- 
lease, indicating abnormally slow capillary refilling. 



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The extremities and nose are usually cold in cases of severe wounding. 
The general body temperature may also be reduced but some patients may 
have a slight elevation of temperature. The forehead becomes cold in the 
gravest cases only. 

Constriction of peripheral veins is characteristic of the moderately and 
severely wounded. Veins normally large are reduced to mere threads; filling 
is poor when the venous return is obstructed, and only a little dark blood 
may be obtained on venipuncture. Venous blood is more easily obtained and 
is redder in less severe cases. The presence of constricted veins and cold 
extremities is an important sign in moderate weather but may be less signi- 
ficant when the environmental temperature is low. 

Respiratory rate is often slightly or moderately increased in the severely 
wounded. Breathing of the air -hunger type is seen in the severely exsanguinated 
and i n cases with a large pneumo- or hemothorax. An increased respiratory 
rate due to apprehension is controlled by a sedative. Extreme restlessness 
is rare. It is seen in association with air hunger. Manifestations of pain are 
neither marked nor common in the severely shocked. 

Dryness of the tongue is frequently present in the wounded. It is impor- 
tant to note such cases as they require plenty of saline or glucose-saline in 
the course of resuscitation in .addition to the plasma and blood considered 
necessary. Thirst is present in such cases and is seen also following moder- 
ate to severe blood loss in well hydrated individuals. 

The volume of the pulse is of much greater significance than the rate. It 
gives an indication of the volume of blood flowing through the vessels. A 
pulse of poor volume indicates that the patient is in a precarious state, even 
though the blood pressure may be at or above normal levels. The pulse rate 
is usually accelerated, but may be normal or even slow in some cases. Rates 
in excess of 140 should be regarded as serious. 

The systolic blood pressure may be below normal, normal, or markedly 
• - elevated (160-190 mm.) in severely shocked patients. It must not be used as 
the sole criterion of the patient's condition, but rather correlated with the 
observations noted above. Prolonged low blood pressure Cb&low 80) is with- 
stood poorly and calls for rapid fluid-replacement therapy. Hypertensive 
cases show a return of the pressure to normal when transfused. 

A variation in the systolic blood pressure in the course of the respiratory cy- 
cle is frequently seen in the severely wounded. A fall of 10 to 20 mm. may occur in 
inspiration. This is taken to indicate an inadequate venous return to the heart. It 
tends to disappear as the patient is resuscitated. This condition is often seen 
after an anesthetic, probably as a result of peripheral vasodilation. A diastolic 



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sound which is indistinct or difficult to obtain is a further sign of the serious- 
ness of the patient's condition. 

Resuscitation : Relief of pain is best achieved by injecting morphine, 0.01 
to 0.015 Gm. intravenously. This method of administration gives quick posi- 
tive relief and avoids the possibility of overdosage from simultaneous absorp- 
tion of morphine from the sites of several subcutaneous injections when the 
circulation improves. Every effort should be made to secure rest and quiet. 

There is frequently a tendency to overheat a seriously wounded patient. , 
Heat, by overcoming the protective peripheral vasoconstriction, may aggra- 
vate the patient's condition and thereby lead to a further fall in blood 
pressure. Blankets alone should be applied to the severely shocked until a 
transfusion is well under way, at which time one or two hot water bottles 
with a blanket between them and the patient may be used. In patients with 
very poor peripheral blood flow even moderately warm water bottles placed 
next to the skin may cause burns. "Keep the patient comfortable" is a good 
motto. 

Elevating the foot of the stretcher or bed may cause some improvement 
in the blood pressure of the moderately wounded. 

Oxygen should be given to patients with cyanosis, particularly if they are 
known to have chest injury. 

Fluids by mouth are important if given a sufficient time before operation. 
It is better to give frequent small drinks rather than large single ones which 
tend to make the patient vomit. Patients with abdominal wounds should be al- 
lowed to rinse their mouths with but not swallow fluids. 

Fluid-replacement therapy is by far the most important means of. combat- 
ting shock. Generally speaking, a case which has been wounded severely enough 
to require resuscitation has lost at least 700 to 1,000 c.c.of blood. To re- 
place this there is no question that blood of good quality is the fluid of choice. 
There are two factors which make it necessary to modify the exclusive use of 
blood for transfusions: 

1. It is impossible to provide, and keep in suitable condition the amount 
of blood that would be required. 

2. Even with the strictest care in preparing and keeping stored blood, 
some blood when transfused will hemolyze to a certain extent. 

If massive blood transfusions (6 to 8 bottles) are given, the chances of 
getting post-transfusion hemolysis with possible kidney damage are greatly 
increased. The urgent immediate need of most casualties is a restoration 

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of blood volume rather than of the oxygen- carrying powder of red cells. Con- 
sequently, plasma should take the place of part of the blood in cases requiring 
transfusion. 



The importance of speed in initial administration of fluid is a point which 
is not always fully appreciated. In severe wounds, where the blood pressure 
is below 80, two bottles of plasma and one of blood or vice versa should be 
given within one-half to three-quarters of an hour. If one transfuses too 
slowly, the pressure may never rise. In those patients with less serious 
wounds and with normal or mild reductions in blood pressure, it is better to 
run in the fluids more slowly. 

Two to three bottles of blood or plasma restore the blood pressure in 
most cases, but measurement has shown that an additional bottle or two will 
be required actually to restore the blood volume. 

If greater amounts of fluid than this are required to restore the patient, 
it is well to reexamine him carefully to ascertain the cause. Bleeding may 
have recurred; or gas infection may have developed in injured muscle. In 
such cases even adequate restoration of the blood lost may not restore the 
pressure to normal. Extensive muscle injury may have a similar effect pos- 
sibly because of toxins liberated from muscle. These cases require surgery 
even if their blood pressure cannot be restored to normal, and in fact the 
surgical control of bleeding, and the removal of dead and infected muscle is 
a prerequisite to resuscitation. Fat embolism, although it is not common, 
may explain the failure of some patients to improve with resuscitation. 

Rapid transfusions of blood or plasma often cause severe rigor. In ex- 
treme cases morphine 0.01 Gm. may be given intravenously and the rapid 
transfusion continued. This usually controls the rigor. In less urgent cases 
slowing the rate or interrupting the transfusion for a short time is usually 
effective. 



It is not desirable to administer cold blood. It constricts veins and 
seriously reduces the rate at which it can be given. Blood may be warmed 
by leaving it at room temperature for an hour or two. Especially should 
this be done if many casualties are expected. To remove the extreme chill 
of a bottle of blood quickly, one may place it in luke-warm water for 10 to 
15 minutes, or one may place hot water bottles over the intravenous tubing 
leading to the patient's arm. Blood should never be overheated, e.g. by plac 
ing in a can of water on a stove. Excessive heat will hemolyze blood. Such 
blood may lead to irreparable renal injury if used for transfusion. 

Saline or preferably glucose-saline may be given profitably to all pa- 
tients being transfused. Most casualties have depleted water stores if not 
frank dehydration. More than one bottle o f such fluid is indicated 



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EESJBICiED 



preoperatively in patients with abdominal wounds who have dry tongues . This 
may be given either before or after the pressure has been adequately re- 
stored; if injected before, it should be given quickly. Patients without ab - 
dominal injury should be encouraged to take fluids by mouth providing they 
are not going to operation within a short time. 

The adequacy and effectiveness of transfusion can be judged in several 
ways. The return of warmth to the skin is one of the best. It indicates that 
the circulation has improved and vasoconstriction relaxed. Elevation of a 
low blood pressure to normal levels and its maintenance there, or the de- 
pression of an elevated pressure, are valuable indices of improvement. The 
changes in blood pressure may occur before or without return o f warmth to. 
the skin, and therefore give a premature sense of security. A decrease in 
heart rate and an improvement in the pulse volume are valuable additional 
signs of improvement) but the heart rate may not decrease if it has not pre- 
viously been over 120. The respiratory variation in the level of s y s t o 1 i c 
blood pressure decreases with an adequate response and the diastolic sound 
becomes clearer cut. 

Resuscitation of Cases with Specific Types of Injury 

Head Injuries: If there is evidence of intracranial injury, these cases 
should not receive transfusions unless there are other gross wounds. 

Chest Injuries : Ideally these cases should not be transfused until the 
chest is aspirated. However, in severe shock a slow blood transfusion should 
be started immediately. The amount of blood withdrawn from the chest is an 
index of the amount of replacement required. It is believed by some surgeons 
that it is better to "under-transfuse" these cases in order to avoid pulmonary 
edema, i.e., to give 300 c.c, less than the amount withdrawn from the chest. 
Sucking chest wounds must be closed by air-tight packs until such time as 
they can be closed surgically. 

Abdominal Injuries: The amount of blood lost and the depth of shock in 
penetrating wounds of the abdomen vary greatly. An estimate must be made 
on the basis of the clinical signs previously enumerated and the amount o f 
blood or plasma to be given calculated accordingly. When the hemorrhage 
has been large, as with laceration of the spleen* the transfusion must be rapid 
and composed of at least as much blood as plasma. A total of 6 to 8 bottles 
may be required. 

Most patients with abdominal injury require an average of two bottles of 
blood and two of plasma. If there is much dehydration, it is advisable to give 
glucose -saline as well. The saline and plasma may be given first. The blood 
is best reserved for administration immediately before and during the operation. 



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Large Injuries : Large injuries such as those with extensive muscle dam- 
age (3 fistfulls) associated with compound fractures should be given at least one 
bottle of blood followed by two of plasma. Many require much more. As men- 
tioned before, pressures may return to normal with one or two bottles but a 
further amount of fluid equal to that already given is needed to restore the 
blood volume. In cases requiring 5 to 6 bottles of fluid to restore their blood 
pressure, one or two additional bottles are usually sufficient. 

In cases when rapid and adequate transfusion is not successful, operation 
is indicated even in the presence of low blood pressure. 

Fractures : Patients with fractures or amputations involving only a leg 
or an arm can be resuscitated with plasma alone, unless there is blood loss. 
Patients with cross fractures of the femur or multiple fractures usually re- 
quire one or two bottles of blood as well. In such cases it is wise to start 
administration of blood just before operation, since considerable operative 
blood loss must be expected. 

Postoperative Resuscitation : Severely wounded patients , especially 
those with abdominal injuries who, following operation, have low blood pres- 
sure and circulatory impairment, should receive careful supervision by a 
medical officer. 

These cases should be handled as little as possible and should not be 
taken off the stretcher to be put into bed. The foot of the stretcher should 
be raised about one foot above the head. They should have the blood pres- 
sure checked every one-half to one hour. If there is evidence that much 
blood was lost at operation, replacement is indicated. 

When the patient's circulatory adjustments have been made, he may be 
transferred to bed. Less serious cases are better put to bed immediately, 
preferably while still under the anesthetic. 

Abdominal cases on continuous gastric suction should have at least 3,000 
c.c. of intravenous fluids every 24 hours of which at least 1,000 c.c. should 
be plasma and the rest glucose -saline. Some cases lose large amounts of 
fluid from their gastric suction and may require 4,000 c.c. daily. Signs of 
adequate therapy are a moist tongue and a urinary output of 1,000 c.c. or 
more in 24 hours. A careful check on the state of the lungs will aid one in 
avoiding the administration of excessive amounts of fluid. 

The need of serious postoperative cases for careful supervision b y a 
trained medical officer is not always recognized. Several surgeons have com- 
mented on the frequency with which patients die from shock a few hours follow- 
ing operation. If the same attention were paid to these cases postoperatively as is 
given in the resuscitation ward, a number undoubtedly could be saved. 



Burned News Letter, Vol. 5, No. 1 RESTRICTED 



Inter capillary Glomerulosclerosis: Laipply et al. have studied the clini- 
cal records, autopsy protocols and microscopic sections of 332 patients in 
order to determine the incidence of intercapillary glomerulosclerosis among 
diabetic and other patients and to correlate its occurrence and development 
with distinctive clinical manifestations. 

Intercapillary glomerulosclerosis was first described by Kimmelstiel 
and Wilson in 1936. They reported 8 cases in which different stages of the 
renal lesion were present. In all but one instance there was a history of 
diabetes mellitus, usually of long standing, widespread edema of renal origin 
and pronounced albuminuria. In some cases hypertension and renal insuf- 
ficiency also were present. 

The typical lesion of intercapillary glomerulosclerosis is usually spheri- 
cal and occasionally oval. It varies from 20 to 110 micra in maximal dia- 
meter and is made up of faintly acidophilic acellular hyalinized tissue. With 
low magnification it appears homogenous, but high magnification reveals 
small vacuoles, and the Wilder silver stain frequently makes evident circum- 
ferential lamination. The hyaline material does not have the specific staining 
properties of amyloid. It stains either red or blue with the Mallory-Heidenhain 
azocarmine and pale yellow with the Van Gieson stain. Small droplets of fat 
are not uncommonly present in the hyaline material. These are, however, no 
more numerous and no larger than the lipid droplets which occur in the kidneys 
of non-diabetic persons and of persons with diabetes without typical lesions. 
Consequently, it is impossible to attach much differential significance to these 
lipid deposits. At the periphery of the lesion there are usually one or more 
concentric layers of flattened cells, presumably endothelial. The involved 
glomeruli sometimes are small but more frequently are of normal or larger- 
than^normal size. 

Laipply and his co-workers found intercapillary glomerulosclerosis to 
be a common lesion in their series of patients with diabetes, occurring in 63.7 
per cent of 124 patients. On the other hand, the characteristic lesions were 
found in only 5 of 208 patients with renal disease but without diabetes. No 
demonstrable relation was found between the degree of its development and 
the duration or degree of the diabetes. Among diabetic patients with inter- 
capillary glomerulosclerosis, hypertension was present in 64.4 per cent, 
albuminuria in 81 per cent, the nephrotic syndrome in only 6.3 per cent and 
uremia in 17.7 per cent. No correlation was found between the degree of 
intercapillary glomerulosclerosis and renal arterial or arteriolar sclerosis. 

Intercapillary glomerulosclerosis was found just as frequently as hya- 
linization of the islets of Langerhans at necropsy in patients who had diabetes 
mellitus. (Arch. Int. Med., Nov. '44.) 

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Treatment of Condylomata Acuminata with Podophyllin: Condylomata 
Acuminata, frequently designated by the misnomer "venereal warts", are 
annoying growths of uncertain etiology, usually affecting the genitalia. Treat- 
ment has hitherto been unsatisfactory. 

Recently Culp and Kaplan (Annals of Surgery, 120:251, August 1944) re- 
ported prompt and effective cures in a series of 200 cases of condyloma 
acuminata treated with podophyllin. The drug, a resin of Podophyllum Pel- 
tatum, is described as a light-brown, or greenish-yellow powder. For treat- 
ment of condylomata acuminata the authors recommend that a 25 per cent 
suspension of the powdered drug in mineral oil be applied to the surface of 
the lesion with a cotton swab, and be washed off 24 hours later. They state 
that the treatment is painless, requiring no anesthesia nor hospitalization, 
and that no systemic nor immediate local reactions occur. According to 
their description, the growths appear blanched within a few hours after ap- 
plication of the suspension, and become necrotic 24 to 48 hours later. The 
condylomata slough on the second or third day, and promptly disappear, 
leaving no ulceration nor scarring. 

All of the 200 cases reported in this series were cured regardless of 
the number, size, location or duration of the growths. The lesions were 
located on the penis of 168 patients, on the female genitalia of 15 patients, 
within the male urethra of 10 patients, on the anus of 4 patients, on the male 
perineum of 2 patients and on the scrotum of 1 patient. Only one application 
was required to cure 81.5 per cent of the cases, and an additional 14.5 per 
cent recovered after a second treatment. In no instance were more than four 
applications necessary. In 72.5 per cent of the cases complete cure was ef- 
fected within 4 days, and in only 6.5 per cent was recovery delayed longer 
than 8 days. No discomfort was experienced by 83.5 per cent of the patients, 
and only 2 per cent required any sedation. There were 9 known recurrences 
within 1 to 6 months. The recurrent lesions disappeared after one treatment 
in 8 instances, and two treatments in the other. Several patients were fol- 
lowed for as long as. 9 months without recurrence. 

The authors have found the oil suspension and powdered drug also to be 
useful in removing excessive granulation tissue from surgical wounds, but of 
no value in the treatment of typical horny verrucae, of condylomata which oc- 
cur late in the course of syphilis, or of benign rectal polypi. They refer to a 
report of excellent results obtained by Tomsky, Vickery and Getzoff (Journal 
of Urology, 48:401, 1942) in the treatment of granuloma inguinale with podo- 
phyllin. 

At the Rockefeller Hospital recently there has been an opportunity to try 
therapy with podophyllin upon a patient with condylomata acuminata. Lesions 
had appeared about 6 months previously, increasing in size and number to a 



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total of 9 at the time of treatment. They were located on the shaft of. the 
penis beneath the prepuce adjacent to the coronal sulcus and the frenum. 
After one application of 25 per cent podophyllin in mineral oil, which was 
washed off 24 hours later, the lesions behaved as described by Culp and ■■ 
Kaplan and disappeared in 4 days, leaving a clean, denuded surface. It 
was found that application of boric acid ointment relieved irritation of this 
sensitive area until complete healing had taken place 2 days later. 

Attention is called to this new, useful and apparently effective form of 
therapy. (Nav. Med. Res. Unit at Hosp. of Rockefeller Inst., E. C. Curnen) 

+ jf: + + ^ 

Salt Water Washing for Hospital-Ship Laundries : The procurement by 
the Navy of a detergent powder which permits the use of salt water in laun- 
dries was mentioned in the Burned News Letter of September 29, 1944. 

In medical activities the demands on the laundry are relatively great. 
Consequently, the salt water "soap" is ideally suited for use on hospital 
ships and in advance-base hospitals where supplies of fresh water may be 
restricted. 

The detergent powder cannot be depended on as regards antisepsis. 
Navy Regulations, Article 1324, forbids the use on board ships of sea 
water from polluted harbors. The use of such harbor water even for launder- 
ing and rinsing will be risky, unless bacteriocidal temperatures can be 
maintained. 

Production and procurement have not kept pace with the demand, and 
supply officers requisitioning this detergent powder may experience some 
delay in obtaining it. However, early improvement in this situation is 
anticipated. 

A description of this detergent powder and instructions for its use can 
be found in BuShips letter, JHK336), EN28/A2-11, of July 28, 1944. Instruc- 
tions for its use are given also in BuShips Spec. 51S47CINT), of April 1, 1944 - 
Soap, Salt-Water, Powdered (for Use in Soft, Hard or Sea Water). These in- 
structions are reproduced on a 6 x 8 inch card placed inside the soap container. 

****** 

Control of Tuberculosis in the Navv: A Tuberculosis Control Section 
was recently established in the Preventive Medicine Division. This Section 
assumed the functions previously assigned to the Tuberculosis Case-Finding 
Unit of the Physical Qualifications and Medical Records Division, and is ex- 
panding the case-finding activity into a broader control program. 



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The first responsibility of the Section is supervision of the technical 
and professional quality of the examinations. Complements have been es- 
tablished for both the stationary and the mobile photofluorographic units , 
which examine approximately 10,000 persons each month, such complements 
consisting of one especially- trained medical officer, one X-ray technician, 
one photographic technician, two expert clerical men and two men of lower 
rates as general helpers under- .instruction. 

The second responsibility is case -finding. Photofluorographic equip- 
ment has been made available for the annual examination of personnel under 
the age o f 30 and for the semi-annual examination of personnel 0 f all ages 
who are known to have healed or arrested lesions of tuberculosis. Station- 
ary photofluorographic units have been placed in navy yards, receiving 
barracks, and distribution centers. The choice of location depends solely 
upon the estimated monthly total of examinations; equipment having been 
assigned only when this estimated total approximates or exceeds 10,000. In 
addition, stationary units will be assigned to discharge centers, as such cen- 
ters are designated, for examination of personnel at the time of discharge 
or release from active duty. Eight mobile photofluorographic units, now being 
procured, will provide service to shore stations to which stationary units have 
not been assigned. 

Navy #128 now has stationary photofluorographic equipment. Portable or 
mobile units are being procured for use overseas for examination of service 
and civilian personnel. 

Control measures are being developed along the following lines: 

1. Case -finding. 

, 2. Establishment of a Central Registry of Personnel who have been 
reported by Boards of Medical Survey. 

3. Examination of Contacts. 

4. Periodic Examinations of Arrested Cases. 

5. Development of an Educational Program. 

Examinations of contacts are made as a result of information obtained 
from Reports of Medical Survey and from mass case-finding X-ray examina- 
tions. 

Personnel returned to duty with arrested minimal lesions are reexamined 
by means of an X-ray of the chest at intervals of six months. Personnel with 
arrested lesions returned to limited duty are reexamined by Boards of Medi- 
cal Survey at intervals of six months to determine fitness for full duty. 

It is planned to carry out the educational program, in connection with the 
annual chest X-ray examination, by means of "story-telling" poster series , 
suitably arranged in the dressing rooms and along the waiting line. 



Burned News Letter, Vol. 5, No. 1 RESTRICTED 

Facilities for the study and treatment of all cases found are present in 
all naval hospitals. Two large general hospitals have been especially desig- 
nated to care for tuberculous patients and are provided with all modern 
facilities for the medical and surgical treatment of the disease. Patients 
are retained for treatment until beds in a Veterans' Administration Facility 
become available. 

It is now possible for the commanding officer of a naval vessel to obtain 
for the personnel of his crew the required examinations in most continental 
ports and in Navy #128. A gratifying use of these facilities is already evi- 
dent and their further use is encouraged. Little time is required for the 
examinations, as a well organized photofluorographic unit can examine from 
125 to 150 persons every hour. 

Paragraph 3 of BuMed Letter to All Ships and Stations, P3-3/P3-K054- 
40) dated June 13, 1944, reads as follows: 

"Roentgenograph^ examination of the chest 'of all Naval and Marine 
Corps personnel on active duty who have not been so examined during the 
last twelve months shall be made at the earliest opportunity. Thereafter, 
chest examinations of personnel on active duty under the age of 30 shall, if 
practicable, be made at least once a year." 

This is construed to mean that all persons being "processed" through 
a naval activity in which a photofluorographic unit is available, who require 
a chest X-ray, be so examined. The successful attainment of complete 
coverage of all personnel will depend upon the establishment of a definite 
routine, similar to that used in checking immunization procedures, at naval 
activities having photofluorographic equipment. (Prev. Med. Div., BuMed - 
T. J. Carter) 

$ $ ~ $ jf $ $ 

Salt Tablet with Prolonged Solution Time: A salt tablet impregnated 
with cellulose acetate or Cellulose nitrate has been developed at the Naval 
Medical Research Institute. By virtue of its cellular structure, this tablet 
dissolves very slowly, usually within 80 minutes. This slowly dissolving, 
impregnated tablet causes significantly fewer gastrointestinal symptoms 
than the currently-used fast dissolving salt-cornstarch tablet and the 
formerly-used pure salt tablet. Evidence is submitted which shows that the 
cellulose stroma of the impregnated tablet passes harmlessly through the 
gastrointestinal tract. The impregnated salt tablets withstand well the high 
temperatures and humidity of tropical climates, as well as the friction and 
impacts of handling. They can be made without difficulty by mass- 
production methods. CX-214) 



r 



r 




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Skin Disease of Unknown Etiology : During the. latter half of 1943 and 
throughout 1944 a group of related skin disorders, not classifiable as be - 
longing to any of the established dermatologic entities, has appeared in mili- 
tary personnel in the Pacific. Most of the cases have originated in the New 
Guinea area; The etiology is unknown. 

The onset is usually gradual. There is considerable variation in the 
character of the lesions, both early and late in the disease. The initial le- 
sion may consist of small pruritic areas covered with a fine scale or of a 
lichenoid papule which is frequently raised and has a rough verrucous sur- 
face. Such lesions may appear singly or in patches. Characteristic loca- 
tions of onset are the face, scalp, arms, hands, legs, buttocks and genitalia. 
The initial lesions may regress without further spread. However, if the 
condition progresses, all lesions gradually take on a dark-red or cyanotic 
color. 

The papules and scaly areas may gradually spread in a patchy manner ■ 
and may or may not become generalized. In the more extensive cases the 
skin becomes thickened and dark red, particularly in the axilla and groin, 
and under conditions of increased heat and moisture. In such cases the 
lesions may become eczematoid in nature with considerable oozing, or may 
become frankly raw. Pyodermia is an occasional complication. Afewof the 
dermatitic cases run a febrile course and the lesions progress to a stage of 
exfoliation. In the rare very severe cases the cycle of inflammation and ex- 
foliation may be repeated one or more times. 

Certain individuals with this syndrome develop a condition which is com- 
patible with a diagnosis of hypertrophic lichen planus. Atypical fe'atures, 
however, are that the lesions are darker in color, are more extensive and 
elevated than those ordinarily seen in lichen planus and are associated with 
lesions similar to those described above. 

The prognosis in this group of skin disorders is uniformly good, although 
recovery may be slow in the' small number of individuals who develop the more 
extensive lesions. It must be emphasized in this regard that the disease is ex- 
tremely variable in the extent of body involvement as well as in the type of le- 
sion. Small patches on the face or extremities may clear up within a few weeks 
while a generalized dermatitis may require several months for complete recovery 

Treatment is supportive in character. Emollient preparations, adequate 
diet and good nursing care appear to be the most effective means of therapy. 
Bismuth injections have been tried for the lichenoid type of eruption without 
benefit and are possibly harmful. Sulfonamides and penicillin have been given 
with uncertain results in a small group of cases, but are possibly deserving of 
trial in severe cases, particularly those of an eczematoid nature or complicated 
by pyodermia. (Prof. Div,, BuMed - F. A. Butler) 



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Public Health Foreign Reports : 
Disease pl ac e 
Plague 



Date 



Number of Cases 



Smallpox 



Typhus Fever 



Yellow Fever 



Algeria, Algiers 


Sept. - Oct. '44 


70 (23 fatal) 


Belgian Congo 


Sept. 23-30, '44 


2 


Fr. West Africa 






LJcLfS.a,J. 


Opt 1 4-91 '44 


1 3 (fatal} 


Madagascar 


Sept. 11-20, '44 


4 


Senegal 


Sept. 11-20, '44 


8 (7 fatal) 


Union of So. Africa 


Oct. 1-14, '44 


2 


Bolivia 


Sept. '44 


154 (54 fatal) 


Brazil 


Jan. 1-Oct. 7, '44 


7,812 (11 fatal) 


Colombia 


Jan. 1 -May 31, '44 


1,157 (12 fatal) 


Panama 


Sept. '44 


1 


logo 




7ft H R -fatal\ 
fo \±UIdXeU./ 


Union of So. Africa 


May 1-Oct. 1, '44 


417 (129 fatal) 


Algeria 


Oct. 1-10, '44 


8 


Bolivia 


Sept. '44 


25 (5 fatal) 


Egypt 


Sept. 16-23, '44 


31 (4 fatal) 


Guatemala 


Sept. '44 


117 (15 fatal) 


Hungary 


Sept. 16-23, '44 


9 


Mexico 


Sept. '44 


147 


Peru 


Aug. '44 


79 


Slovakia 


Jul. 30- Aug. 12, '44 


3 


Nigeria 


Aug. 15, '44 


1 


Venezuela 


Jul. 16-Sept. 10, '44 


21 (suspected, 






9 fatal) 




Oct. 16, '44 


1 



(Pub. Health Foreign Reps., Nov. 17 & Dec. 1, '44.) 

****** 



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< r 

Burned News Letter, Vol. 5, No. 1 RESTRICTED 



To: All Ships and Stations. BUMED-Y-BHL 

A2-2/EN10 

Subj: Quarterly Sanitary Report, Establishment of, and 

Discontinuance of Monthly and Annual Sanitary 30 Nov 1944 
Report for Shore Stations Only (Including Hospi- 
tals) - Advance Change in Manual of Medical De- 
partment. 

Refs: (a) Manual of Medical Department, pars. 2691, 2697, 2698, 2700 and 2701. 

(b) BuMed Itr A9-1/P2-4Q13), of 25 Nov 1943, "Historical Data, Inclu- 
sion of in Annual Sanitary Report"; N.D. Bui. Cum. Ed. 1943, 43-1636, 
, p. 492. 

1 . The changes in the Manual of the Medical Department outlined herein shall 
be made in the present edition pending a general revision of the manual. 

2. The changes in sanitary reports for shore stations, outlined herein, in no 
way affect the present requirements and procedures for submitting the annual 
sanitary report for ships. 

3. The annual sanitary report for 1944 shall be submitted as usual. Effective 
1 January 1945, monthly and annual sanitary reports for shore stations, includ- 
ing hospitals, are hereby canceled and superseded by quarterly sanitary reports. 

4. Paragraphs 2691, 2697, 2698, 2700 and 2701 of the Manual of the Medical 
Department (Ref. (a)) are canceled. Also, Ref. (b) is. modified as indicated 
below. The following instructions shall govern the preparation of the sanitary 
reports for shore activities (including hospitals) , and shall become paragraph 
2698 of the present edition of the Medical Department Manual: 

"2698. Quarterly Sanitary Report, Shore Stations. - (a) The medical officer 
of each shore station (including hospitals) shall submit the quarterly sanitary 
report to the Bureau of Medicine and Surgery as of 31 March, 30 June, 30 Sep- 
tember and 31 December to be forwarded not later than the 15th day of the fol- 
lowing month. It shall be routed via official channels for endorsement and 
comment with reference specifically to all recommendations and action to be 
taken thereon. It is essential that all endorsers include brief statements as to 
desirability of taking action on recommendations. In cases of specific recom- 
mendations made for action by higher authority, the practice of stating "For- 
warded" as the only endorsement will defeat a major purpose of the report. 
District medical officers shall discourage this practice and endeavor to secure 
endorsements that constitute an evaluation of recommendations and proposed 
remedial action. Copies of endorsements and comments shall 'be returned for 
information of reporting medical officer. 



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Burned News Letter, Vol. 5, No. 1 RESTRICTED 

"(b) The discontinuance of the monthly sanitary report does not affect the 
responsibility of medical officers to conduct frequent inspections of sanitary 
conditions, and to submit such additional reports as are deemed necessary to 
the commandant and Bureau of Medicine and Surgery. The purpose of the 
change is to provide the Bureau of Medicine and Surgery with information that 
will be more helpful in the direction of a sanitary program for the Navy than 
the former monthly statements of inspections completed. 

"(c) Occurrence of food poisoning, milk or water-borne infections, in- 
fectious disease outbreaks believed to be insect borne or related to the preva- 
lence of rodents, or otherwise attributed to insanitary conditions, shall be re- 
ported immediately through official channels to the Bureau of Medicine and 
Surgery, using the subject "Special Sanitary Report." 

"(d) Preparation of the new quarterly sanitary report shall be guided by 
the following three major purposes which these reports are intended to serve. 
First, to inform the commanding officer of the sanitary conditions on the sta- 
tion, in order to recommend for his consideration needed corrective actions 
and to report on actions initiated or under way during the period covered. 
Second, to make recommendations and to report on actions relative to correc- 
tive measures which fall under the cognizance of higher authority. Third, to 
contribute information which will serve as basis for (a) establishing sanitation 
policies, standards, and practices of the Navy; (b) initiating research on or for 
improving equipment, facilities, procedures, organization for sanitation; and 
(c) securing action of Navy Department bureaus having cognizance over acti- 
vities that are causing insanitary conditions in particular areas. 

"(e) The quarterly sanitary report shall conform to the following outline, 
but deviations may be made if deemed essential by the medical officer in the 
presentation of pertinent or related facts: 

"QUARTERLY SANITARY RE PORT 
"OF THE 



"For the period ending 

"1. Average Strength 

• "State the average strength for the period covered by the report, showing 
the number of officers, enlisted personnel and civilians and designating the 
number of male and female under each of the three categories. Average strength 
of enlisted personnel is obtained from number of rations issued and commuted. 

"2. Changes in Basic Data 

" 'Basic Data' is interpreted to include those environmental factors or con- • 
ditions and structural details or installations of a fundamental or relatively 



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Burned News Letter, Vol. 5, No. 1 RESTRICTED 



fixed nature that are related to health and sanitation. For example, topography 
and climate, buildings, prison spaces, water supply and sewerage installations, 
and sick-bay facilities. 

"If general basic data for the station has been submitted in an earlier sani- 
tary report, each quarterly report should include only an account of the changes 
in basic data occurring during the particular quarter. 

"3. Evaluation of Sanitation in Terms of Fixed Standards and Minimum Require- 
ments 

"Fixed standards and minimum requirements shall be interpreted as those 
established by Navy Regulations, Manual of the Medical Department, and Bureau 
of Medicine and Surgery directives and recommendations. 

"This section of the report shall give consideration to such subjects as: 
living quarters, toilet and bathing facilities, water supply and cross connections, 
swimming pools, mess sanitation, fresh milk supply and Navy ration. 

"The content shall be limited to those conditions that do not meet fixed 
standards and minimum requirements. The reasons for failure of not meeting 
the standards, and an appraisal of the potential danger shall be discussed in de- 
tail. 

"4. Evaluation of General Sanitary Conditions. 

"General sanitary conditions are interpreted to include such subjects as 
disposal of sewage, garbage and refuse; prevalence and control of insects and 
rodents; adequacy of clothing and laundry facilities; fungus infections; extra 
cantonment health hazards; industrial health hazards; sanitary discipline and 
general 'housekeeping' standards. 

"Discussion of these subjects shall be limited to practices that are not 
considered satisfactory in .the opinion of the medical officer. 

"5. Special or Unusual Sanitary Problems 

"This section shall include a detailed discussion of any special or unusual 
sanitary problems that may develop during the quarter and action taken to cor- 
rect the situation. 

"6. Recommendations 

"The recommendations of the medical officer shall consist of three sec- 
tions: 

"A. Action taken and progress to date of recommendations made (if any) ■ 
in last sanitary report and any special reports made during the last quarter, 
including sanitary surveys and sanitation recommendations made by naval 
epidemiology units and by other investigators and inspectors. 

"B. Recommendations for action within the local command, or a statement 
of action being taken or to be taken within the command relative to unsatisfac- 
tory conditions discussed in the current quarterly report. 



b-Jied News Letter, Vol. 5, No. 1 RESTRICTED 



"C. Recommendations for action by higher authority of a statement of action 
taken or to be taken by authority other than local command in connection with 
conditions discussed in the current quarterly report. 

"(f) For the preparation of the quarterly sanitary report outlined in para- 
graph (e) , the following list of subjects are submitted as an indication of the 
scope of information and problems to be covered in this report. The report 
shall include information pertaining to these subjects only when conditions do 
not meet the Navy sanitary standards and practices. Additional data not included 
in the following list of subjects but which are pertinent to the sanitary problems 
of any station shall be made a part of the quarterly sanitary report; 

"1. Topography and Climate - Drainage, flooding, dust, prevailing winds, 
temperature and humidity extremes and averages. 

"2. Public Buildings - Buildings (other than barracks, galleys, mess 
halls, hospitals, dispensaries, sick bays), with particular reference to sanita- 
tion of entertainment centers, theaters, recreation halls, chapels, club buildings, 
office buildings, and other places where personnel congregate. 

"3. Prison Spaces - Cubic capacity, ventilation, heating, lighting and 
sanitation of cells, 

"4. Facilities for Treatment of the Sick - Sick bay (including dispensary, 
wards, operating rooms, medical storerooms, and venereal-disease prophylaxis 
rooms), capacity in square feet of floor space and cubic feet, number of berths, 
equipment and fittings, ventilation, heating, lighting and arrangements for stor- 
ing medical and surgical supplies, number of sick-bay cots or beds allotted or 
separated off for surgical, medical isolation, psychiatric, urologic and other 
type cases by service. 

."5. Living Quarters - Number of personnel berthed in quarters, parti- 
cular attention being given to overcrowding and ventilation; approximate 
amount of air per person per hour, approximate floor space and air space per 
person; lighting - amount, means, defects; heating - adequacy, means, defects; 
screening; general housekeeping standards. 

"6. Toilet and Bathing Facilities - Facilities in terms of the number 
and ratio to personnel of washbowls, faucets, showers, urinals and water closets. 
Particular attention should be devoted to potential or actual cross connections 
and protection against back siphonage. The discussion should include facilities 
for civil employees as well as naval personnel. 

"7. Water Supply - Source of supply, protection of source from contami- 
nation, method of purification, continuity and adequacy of operation and labora- 
tory control of filter plant, method of chlorination, cross connections in 
purification plant and distribution system, protection against contamination 
through cross connection of ships' fire and flushing systems to potable supply 
ashore, chlorination of new mains or those emptied for repairs, chlorine resid- 
uals throughout the distribution system, bacteriologic examinations and state- 
ment as to safety and adequacy of supply. 

"8. Swimming Pools and Bathing Beaches - Capacity, bathing load, re- 
circulation of water or frequency of change, filtration, chlorination, bacterial 



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Burned News Letter, Vol. 5, No. 1 



RESTRICTED 



counts, cross connections, adequacy and safety of swimming pools. General 
statement on safety and use of bathing beaches with reference to sewage con- 
tamination or potential sources of contamination and bacterial counts. 

"9. Sanitation of Food Storage Spaces, Galleys (including flight ration 
galleys), Mess Halls, Scullerys - Buildings or space, including Ship's Service 
stores and other places where food is stored, prepared or served; adequacy and 
efficiency of refrigeration and water-heating facilities; cleanliness of food 
handlers and hygiene of civilians employed in places where food is stored, pre- 
pared and served; cleanliness of mess gear, utensils and equipment; screening 
of mess halls, galleys, and other places where food is prepared and served. 
Include messing facilities for civilians employed on the station. 

"10. Fresh Milk Supply (including ice cream and other dairy products) - 
Standards maintained in procurement, handling, preservation, bacteriological 
examination and serving. 

"11. Navy Ration - Quality, adequacy, variety, preparation. 

"12. Disposal of Sewage, Garbage and Refuse - Methods in use, adequacy 
of facilities and efficiency of operation. 

"13. Insect Control - Prevalence of mosquitoes, flies, bedbugs, cock- 
roaches and other insects; control measures and effectiveness. 

"14. Rodent Control - Dangers of the problem (if any) and the effective- 
ness of measures in operation. 

"15. Clothing - adequacy, suitability and laundering facilities. 

"16. Fungus Infections - Prevalence and the effectiveness of control 
measures. 

"17. Extra Cantonment Public Health Hazards that affect, or may affect 
the standards of hygiene and sanitation within the naval establishment or en- 
danger the health of the naval or civilian personnel. 

"18. Industrial Health Hazards - Consider significant, potential, or real 
current exposures of civilian or enlisted personnel to industrial health hazards 
and report the condition or the type of toxic material, number of individuals 
exposed and methods of control. 

"(g) Supplement to fourth quarterly sanitary report, historical data. The 
historical data shall be treated as an annual narrative report to be included 
in the fourth quarterly report only. It shall be prepared on separate sheets 
•and attached to the sanitary report so that upon its arrival at BuMed it may 
be detached and routed to the appropriate office. It shall be a complete account 
in itself, and independent of the sanitary report, even though this may mean a 
certain amount of repetition. While recognizing the necessity for keeping 
reports at a minimum, a complete and accurate record of the experiences of 
the Medical Department in this war will be of inestimable value for informa- 
tional purposes and as a guide to plans for future medical organization and 
activities. With variations according to the type and activity of station, the 
historical data shall be summarized under the following headings: 



Burned News Letter, Vol. 5, No. 1 RESTRICTED 
"1. Chronology 

"Tabular statement giving specific dates, places and outstanding events 
associated with the history of the station (or Marine Corps activity). 
"2. Organization 

"Outline the organization of the station and its relation to the larger 
naval picture (chain of command) . 
"3. Narrative Account 

"Narrative account of medical activities of the station (or Marine Corps 
activity) and of battle experiences, with emphasis on how the medical system 
worked and its relation to the larger naval picture, rather than on clinical medi- 
cine and surgery. (The account shall be complete and accurate, and it shall be 
given whatever classification is necessary for security purposes.) 

"4. Additional Data and Sidelights on Special Subjects When Applicable 
"A. Caring for the sick and wounded. 
"B. Evacuation. 

"C. Noteworthy incidents in relation to epidemic diseases. 

"D. Clinical and professional notes (including data relative to (1) pre- 
ventive medicine, (2) clinical practices, (3) employment of and results from new 
and improved drugs, (4) noteworthy cases, (5) other data). 

"E. Special problems or noteworthy adaptations in regard to supplies 
and equipment. 

"F. Interesting incidents or "human interest" stories to illustrate 
particular points. 

"G. Any other topics believed to be important in the medical history 
of the station (or Marine Corps activity) . 

"5. Conclusion 

"A. Most effective portions of the medical program of the station (or Marine 
Corps activity). 

"B. Least effective portions of the medical program of the station (or Marine 
Corps activity)." --BuMed. W. J. C. Agnew 

+ ijc * * if; j|c , . 



To: All Ships and Stations. BUMED-R-JLA 

P1-1/P2-5 

Subj: Service Number or Officer's File Number, Use of 

of Form NavMed Y and FormNavMed Av-1 Reports 14 Dec 1944 
of Physical Examination. 

1 . In the preparation of reports of physical examination submitted on NavMed 
Form Y or NavMed Form Av-1, it is directed that the file (serial) number of 
officers, Navy and Marine Corps, or the service number of enlisted personnel, 
Navy and Marine Corps, be entered in the space immediately following the 
individual's name, to facilitate proper identification of medical records in the 
Bureau of Medicine and Surgery. <--BuMed. Ross T. Mclntire. 

****** 



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